■膝关节前交叉韧带损伤是常见的,并导致活动减少和膝关节继发性骨关节炎的风险。非急性前交叉韧带损伤患者的治疗可以是非手术(康复)或手术(重建)。然而,没有足够的证据来指导治疗。
■为了确定非急性前交叉韧带损伤和不稳定症状的患者,没有事先康复的手术治疗(重建)策略是否比非手术治疗(康复)更具临床和成本效益。
■务实,多中心,优越性,两组平行组和1:1分配的随机对照试验。由于干预措施的性质,无法进行盲检。
■英国有29个NHS骨科单位。
■有症状(不稳定)非急性前交叉韧带损伤的受试者。
■手术管理组的患者尽快接受了前交叉韧带重建手术,没有任何进一步的康复。康复组的患者参加了物理治疗,仅在康复后持续不稳定的情况下被列入重建手术。初始康复后的手术是许多患者的预期结果,并且在协议范围内。
■主要结果是随机分组后18个月的膝关节损伤和骨关节炎结果评分4。次要结果包括恢复运动/活动,干预相关并发症,患者满意度,对活动的期望,一般的健康生活质量,膝盖特定的生活质量和资源使用。
■在2017年2月至2020年4月之间招募了三百名参与者,其中156名随机接受手术管理,160名接受康复治疗。被分配康复的人中有41%(n=65)在18个月内进行了后续重建,其中38%(n=61)完成了康复且未接受手术。72%(n=113)的手术患者在18个月内进行了重建。在主要结果时间点的随访率为78%(n=248;手术,n=128;康复,n=120)。两组都随着时间的推移而改善。在18个月时,调整后的平均膝关节损伤和骨关节炎结果评分4分在手术臂中增加到73.0,在康复臂中增加到64.6。调整后的平均差为7.9(95%置信区间为2.5至13.2;p=0.005),有利于手术治疗。符合方案的分析支持意向治疗结果,所有治疗效果都有利于手术治疗,达到统计学意义。在18个月时,Tegner活动评分存在显着差异。68%(n=65)的手术患者未达到预期的活动水平,而康复组的这一比例为73%(n=63)。手术并发症组间无差异(n=1,n=2个康复)或临床事件(n=11个手术,n=12康复)。在手术患者中,82.9%的康复患者满意,68.1%的康复患者满意。健康经济学分析发现,与非手术管理相比,手术管理可改善与健康相关的生活质量(0.052质量调整后的生命年,p=0.177),但NHS医疗费用较高(1107英镑,p<0.001)。手术管理计划与康复计划的增量成本效益比为每获得质量调整后的生命年19,346英镑。使用每个质量调整后的生命年阈值20,000-30,000英镑,在英国,手术管理具有成本效益,成为最具成本效益的选择的可能性分别为51%和72%,分别。
■并非所有手术患者都接受了重建,但这并不影响试验解释.对物理治疗的坚持是零散的,但试验设计得很务实.
■非急性前交叉韧带损伤患者的手术治疗(重建)优于非手术治疗(康复)。虽然物理治疗仍然可以带来好处,晚期出现的非急性前交叉韧带损伤患者从手术重建中获益更多,而不会延迟之前的康复期.
■验证性研究以及探索保真度和依从性影响的研究将是有用的。
■本试验注册为电流控制试验ISRCTN10110685;ClinicalTrials.gov标识符:NCT02980367。
■该奖项由美国国立卫生与护理研究所(NIHR)健康技术评估计划(NIHR奖项编号:14/140/63)资助,并在《健康技术评估》中全文发布。28号27.有关更多奖项信息,请参阅NIHR资助和奖励网站。
这项研究的目的是找出是否更好地提供外科重建或康复首先患者与他们的前交叉韧带的长期损伤在他们的膝盖。这种损伤会导致膝盖的物理让路和/或感觉不稳定(不稳定)。不稳定会影响日常活动,工作,运动并可导致关节炎。这个问题有两种主要的治疗选择:非手术康复(物理治疗师的规定锻炼和建议)或外科医生进行手术以替换受损的韧带(前交叉韧带重建)。尽管研究强调了最近受伤的膝盖的最佳选择,对于长期受伤的患者来说,最好的管理方法并不为人所知,可能发生在几个月前。因为手术对NHS来说是昂贵的(每年约1亿英镑),查看所涉及的成本也很重要。我们进行了一项研究,招募了来自29家不同医院的316名非急性前交叉韧带损伤患者,并将每位患者分配给手术或康复作为治疗选择。我们测量了他们在特殊功能和活动分数方面的表现,患者满意度和治疗费用。两组患者均有明显改善。如果非手术治疗不成功,预计康复组中的一些患者会希望手术。最初接受康复的患者中有41%随后选择接受重建手术。总的来说,分配到手术重建组的患者在膝关节功能和稳定性方面有更好的效果,活动水平和治疗满意度高于非手术康复组患者。两种治疗选择都很少有问题或并发症。尽管手术是一种更昂贵的治疗选择,在英国环境中,它被发现具有成本效益。可以在与前交叉韧带受伤的患者的共同决策中讨论证据。两种管理策略都导致了改进。虽然康复策略可能是有益的,尤其是最近受伤的病人,建议后期出现的非急性和更长期的前交叉韧带损伤患者接受手术重建,而不必延迟一段时间的康复。
UNASSIGNED: Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment.
UNASSIGNED: To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation).
UNASSIGNED: A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out.
UNASSIGNED: Twenty-nine NHS orthopaedic units in the United Kingdom.
UNASSIGNED: Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee.
UNASSIGNED: Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol.
UNASSIGNED: The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage.
UNASSIGNED: Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively.
UNASSIGNED: Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic.
UNASSIGNED: Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation.
UNASSIGNED: Confirmatory studies and those to explore the influence of fidelity and compliance will be useful.
UNASSIGNED: This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367.
UNASSIGNED: This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.
The study aimed to find out whether it is better to offer surgical reconstruction or rehabilitation first to patients with a more long-standing injury of their anterior cruciate ligament in their knee. This injury causes physical giving way of the knee and/or sensations of it being wobbly (instability). The instability can affect daily activities, work, sport and can lead to arthritis. There are two main treatment options for this problem: non-surgical rehabilitation (prescribed exercises and advice from physiotherapists) or an operation by a surgeon to replace the damaged ligament (anterior cruciate ligament reconstruction). Although studies have highlighted the best option for a recently injured knee, the best management was not known for patients with a long-standing injury, perhaps occurring several months previously. Because the surgery is expensive to the NHS (around £100 million per year), it was also important to look at the costs involved. We carried out a study recruiting 316 non-acute anterior cruciate ligament-injured patients from 29 different hospitals and allocated each patient to either surgery or rehabilitation as their treatment option. We measured how well they did with special function and activity scores, patient satisfaction and costs of treatment. Patients in both groups improved substantially. It was expected that some patients in the rehabilitation group would want surgery if non-surgical management was unsuccessful. Forty-one per cent of patients who initially underwent rehabilitation subsequently elected to have reconstructive surgery. Overall, the patients allocated to the surgical reconstruction group had better results in terms of knee function and stability, activity level and satisfaction with treatment than patients allocated to the non-operative rehabilitation group. There were few problems or complications with either treatment option. Although the surgery was a more expensive treatment option, it was found to be cost-effective in the UK setting. The evidence can be discussed in shared decision-making with anterior cruciate ligament-injured patients. Both strategies of management led to improvement. Although a rehabilitation strategy can be beneficial, especially for recently injured patients, it is advised that later-presenting non-acute and more long-standing anterior cruciate ligament-injured patients undergo surgical reconstruction without necessarily delaying for a period of rehabilitation.